Wrong site surgery – wrong tooth extraction

HSIB legacy content

This investigation was carried out by the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy.

National investigation

Our investigation looked at the risks to identifying the correct tooth for extraction in dental practice.

The extraction of a tooth is an invasive procedure undertaken in a variety of settings. Despite national and local efforts to introduce safety standards for invasive procedures, errors continue to occur.

When a permanent (adult) tooth is extracted in error it is deemed a wrong site surgery. When considered along with other forms of invasive procedures, such as injections in the eye, wrong side chest drains and skin lesion removal, wrong tooth extraction was the most frequently reported type of wrong site surgery over the last five years.

Reference event

The investigation followed the case of a 7-year-old. They were referred by a general dental practitioner to the local district care trust for fillings to their permanent molar teeth and the extraction of a decaying deciduous (milk) tooth.

Following an initial appointment at the health centre, a senior dentist made a treatment plan which included a referral for advice to an orthodontic specialist, fillings and tooth extractions. During the fifth and final appointment, the plan was to remove a single milk tooth that was showing signs of gross decay. During that procedure the neighbouring adult tooth was removed in error. The tooth was re-implanted after a short period outside the mouth and, at the time of the investigation, was healthy.

Having interviewed staff and observed tooth extraction taking place in both hospital operating theatres and dental surgeries, it was apparent that the process in both environments differed.

Investigation summary

This investigation:

Examined how the application of safety standards for invasive procedures is influenced by clinical environment and if this might have a bearing on wrong tooth extraction.
Considered how safety procedures are applied to prevent wrong site surgery in other specialisms where invasive procedures are undertaken in non-operating theatre environments.
Looked at to what extent safety barriers and controls, put in place to prevent the extraction of the wrong tooth, are effective at mitigating the risk of error.

Safety recommendations

NHS England and NHS Improvement

HSIB recommends that NHS England and NHS Improvement should review the Never Events policy and framework and include content to explicitly define the criteria that need to be satisfied for any control to be considered a ‘strong systemic protective barrier’.

We agree that the systemic barriers for some Never Events are not as strong as others and following on from CQC’s thematic review ‘Opening the Door to Change’ commenced a programme of work to review the list of Never Events to identify which barriers are not as strong as was initially thought. Part of this review is also to explore the criteria for a strong systemic protective barrier to identify if this can be clearly defined.

The review of the Never Events Framework and Never Events List will continue to be an ongoing process, as it has been since its first iteration in 2009. We are grateful to HSIB for this recommendation which will continue to support this review process.

We note that the HSIB report also records a safety action A/2021/037 “NHS England and NHS Improvement has reviewed ‘wrong tooth extraction’ against the criteria for a Never Event (as set out in the Never Events policy and framework) and, after due consideration, has removed it from the list of published Never Events with effect from 1 April 2021.”

HSIB defines Safety Actions as “actions required during an investigation to immediately improve patient safety”. The removal of ‘wrong tooth extraction’ from the detailed definition of wrong site surgery was made in the Never Events List revised in February 2021.

As we know HSIB appreciates, this change arose from workstreams commenced after ‘Opening the Door to change’ was published, including workshops with experts in dental surgery that we invited the HSIB investigators to attend. This change was motivated by the need to focus investigation where it can be most effective rather than any immediate patient safety concerns.

Response received on 7 July 2021.

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